Finkelman 2016 chapter 13

Chapter 13

Improving Teamwork: Collaboration, Coordination, and Conflict Resolution

Collaboration

The American Nurses Association (ANA) defines collaboration as “recognition of the expertise of others within and outside the profession, and referral to those other providers when appropriate. Collaboration involves some shared functions and a common focus on the same overall ­mission” (2010b, p. 40). This is a critical competency required to practice in any healthcare ­setting today or to participate in any aspect of healthcare delivery—critical for effective patient-centered, quality care. The increased emphasis on using interprofessional teams to meet the patient’s needs across the continuum of care requires collaboration. Team members and different healthcare providers must be able to work together; recognize strengths and limitations; respect individual responsibilities and expertise; and maintain open, effective communication.

Nurses who have long worked on teams should be familiar with teamwork. Despite this, there continues to be a separation between physicians and nurses, who often work in silos. Nurses and physicians need to work together to ensure that the patient receives the care that is required when it is required. Collaboration involves cooperative effort among all healthcare providers offering care for a patient. This will result in more effective decision making with healthcare professionals working together to accomplish identified outcomes. This is not easy to do. There are professional issues, territory issues, conflicting goals, inadequate communication, and multiple differences; however, despite all of this, effective and efficient care requires collaboration. The system is just too complex to function well without collaboration. The nurse is often the person who must lead the effort to ensure collaboration occurs.

Key Definitions Related to Collaboration

Collaboration is a cooperative effort that focuses on a win-win strategy. To collaborate effectively, each individual needs to recognize the perspective of others who are involved and eventually reach a consensus of a common goal(s). The ANA notes that collaboration involves recognition of expertise and some shared functions (2010a, 2010b). The ANA’s Nursing: Scope and Standards of Practice (2010b) and the Nursing Administration Scope and Standards of Practice (2009) also identify the need for collaboration, emphasizing that all nurses are expected to collaborate. The American Organization of Nurse Executives (AONE) also includes the need for collaboration in its descriptions of leadership competencies, as described in Appendix A.

Key concepts related to collaboration are partnership, interdependence, and collective ownership and responsibility. Considering these concepts helps in understanding the impact of collaboration. Collaboration is also a process. It is not stagnant but rather changes, which requires staff to make adjustments to collaborate with others as situations change. The American Association of Critical-Care Nurses’ nurse competencies in its Synergy Model™ states: “working with others (e.g., patients, families, healthcare providers) in a way that promotes/encourages each person’s contributions toward achieving optimal/realistic patient/family goals; involves intra- and interdisciplinary work with colleagues and the community” (American Association of ­Critical-Care Nurses, 2014). Most people can remember experiences when working with others where the work just seemed to flow with less stress and good communication. This probably means that the people working together were collaborating.

Collaboration should be a positive experience, but this is not always the case. If it is not positive, it will not be effective. If a group of nurses were surveyed, it would be surprising to get a consensus that collaboration was always a positive experience. Often attempts at collaboration mean struggle, conflict, and sometimes ineffective results. Some research has been conducted to assess the effectiveness of collaboration. The Institute of Medicine (IOM) recognizes the importance of collaboration in its rules to guide healthcare provider behavior in the 21st-century healthcare system (2001). The 10th rule, cooperation among clinicians, emphasizes, “cooperation in patient care is more important than professional prerogatives and roles” (p.93). To meet this rule, staff need to collaborate and use effective teamwork, which is weak in the healthcare delivery system.

The Future of Nursing: Leading Change, Advancing Health (Institute of Medicine, 2011) includes collaboration in its content. For example, by noting that nursing leadership competencies need to be applied in “a collaborative environment” (p.8) and “future, primary care and prevention are central drivers of the healthcare system where interprofessional collaboration and coordination are the norm” (p.2). In its recommendations for priorities in research that focus on teamwork, the report lists “identification of the main barriers to collaboration between nurses and other healthcare staff in a range of settings” (p.275).

Barriers to Effective Collaboration

As noted by the IOM, working in isolation with concern for only your own profession is not effective; however, nursing also has much work to do to improve the image of nursing and nursing leadership. Salmon (2007) comments that “improvements in care quality and safety will simply not happen with nurses working by themselves. To take it a step beyond what may seem obvious, it can’t happen just by adding physicians to the equation. It’s going to take the partnered engagement of other clinicians, health administrators, and, ultimately, the public” (p.117). Given these issues, how does the nursing profession arrive at the right balance, one that focuses on nursing and its professional role and needs, while simultaneously developing nurses who can work collaboratively with others to meet positive patient outcomes? Collaboration requires an interactive process. If staff are not willing to interact or have any other barrier to interaction, collaboration cannot take place. Lack of understanding about the roles and responsibilities of others and lack of respect for what others have to contribute interferes with effective collaboration. How much do nurses know about what physicians or social workers or physical therapists or others do and vice versa? If there is distrust, collaboration is hindered because distrust affects willingness to share information, which is an integral component in the collaborative relationship. Collaboration has an impact on whether or not a team is effective or ineffective as team members need to work with each other to develop effective teams and also need to work with others external to the team. Conflict may arise as teams and individual staff work together. Conflict and conflict resolution are discussed in more detail later in this chapter. Although each nurse must develop individual expertise, this expertise must come together with others’ expertise. Few nurses really can work effectively in isolation. Nursing is a profession that requires contact with others—patients, other nursing staff, other healthcare professionals, families, community members, and so on.

Competencies and Strategies to Achieve Effective Collaboration

The increased emphasis on interprofessional teams to meet the patient’s needs across the continuum of care requires effective use of collaboration. The very nature of a team implies that there is more than one idea or approach and not all can usually be accomplished. Decisions need to be made, and this is where collaboration comes into play. It is important to remember that collaboration is also a critical factor in the nurse-patient relationship. Nurses need to actively pursue patient collaboration to ensure that patients are involved in their own care—patient-centered care. The nursing profession has long emphasized patient participation in planning care and in patient education. Collaboration is also important in the development of effective management. To be effective in collaboration, staff require a number of skills:

Communication skills are critical. Verbal skills are the focus; however, in some instances written communication is also important when information and process are described in written format.

Staff members also need to be aware of their own feelings, as was discussed in some of the leadership theories such as emotional intelligence.

Staff need to be able to make decisions to solve problems effectively.

As is discussed in this chapter, coordination is also important when collaborating with others.

Conflicts will arise, which may interfere with collaboration. Staff need to develop negotiation skills to be used in resolving difficult conflicts.

Assessment skills are needed to collect and analyze information as collaborative relationships develop. Box 13-1 highlights these skills.

Collaborative care is central to the success of efficient, outcome-driven care. With the complex healthcare system, specialization of many healthcare professionals, variety of healthcare settings, complex reimbursement systems, technology, and new drugs, collaboration is the only way that patients will receive quality, cost-effective care. Today the healthcare system is an interdependent system with multiple settings and a variety of healthcare professionals, who are dependent on one another. Delivery of care in this complex system requires sharing of information, analysis, critical thinking, clinical judgment, reasoning, clear communication, and ability to use team problem solving. These activities are integral to successful care as the nurse works with many different healthcare providers, within many different healthcare settings, and with the patient and family to ensure quality, cost-effective care for the patient.

Collaborative planning recognizes that collaboration has a positive effect on achieving patient outcomes (Institute of Medicine, 2001). Collaborative planning requires that all parties agree on the mission and goals of the partnership so they have common expectations. All members

Box 13-1 Collaboration: Skills Needed

Effective communication

Awareness of personal feelings

Problem solving

Negotiation

Assessment

Recognition of expertise: Self and others

of the collaborative effort need to commit to open and honest communication, which is essential to sharing. This can be difficult in some HCOs, components of an organization such as specific units or departments, and for some individuals. Those who fear competition and are concerned about power will struggle with the need to share.

Regular evaluation needs to be built into collaborative planning. This evaluation should not only focus on the content of the planning but also on the process—how the collaborative relationship is working. This is something that is often neglected. Power, which is discussed later in this chapter, is related to collaboration. Usually some of the partners in a relationship have more power than others. When partners work through the collaborative planning process, some issues, such as weak communication, level of commitment, expertise, and an understanding that working together is better than working against one another, may interfere with the process. Recognizing these potential issues should be a priority to prevent barriers to success. What can be done to prevent them? Clear communication about purpose, particularly identifying issues from the past that may affect the collaborative planning, can help to clear up misconceptions. Team members need to accept the importance of effort and commit to it. All efforts should be made to keep team members committed. Evaluation data about the collaborative effort can help to improve team functioning.